1
|
Jansen JP, Ragavan MV, Chen C, Douglas MP, Phillips KA. The Health Inequality Impact of Liquid Biopsy to Inform First-Line Treatment of Advanced Non-Small Cell Lung Cancer: A Distributional Cost-Effectiveness Analysis. Value Health 2023; 26:1697-1710. [PMID: 37741446 PMCID: PMC10859998 DOI: 10.1016/j.jval.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 07/28/2023] [Accepted: 08/10/2023] [Indexed: 09/25/2023]
Abstract
OBJECTIVES To perform a distributional cost-effectiveness analysis of liquid biopsy (LB) followed by, if needed, tissue biopsy (TB) (LB-first strategy) relative to a TB-only strategy to inform first-line treatment of advanced non-small cell lung cancer (aNSCLC) from a US payer perspective by which we quantify the impact of LB-first on population health inequality according to race and ethnicity. METHODS With a health economic model, quality-adjusted life-years (QALYs) and costs per patient were estimated for each subgroup. Given the lifetime risk of aNSCLC, and assuming equally distributed opportunity costs, the incremental net health benefits of LB-first were calculated, which were used to estimate general population quality-adjusted life expectancy at birth (QALE) by race and ethnicity with and without LB-first. The degree of QALYs and QALE differences with the strategies was expressed with inequality indices. Their differences were defined as the inequality impact of LB-first. RESULTS LB-first resulted in an additional 0.21 (95% uncertainty interval: 0.07-0.39) QALYs among treated patients, with the greatest gain observed among Asian patients (0.31 QALYs [0.09-0.61]). LB-first resulted in an increase in relative inequality in QALYs among patients, but a minor decrease in relative inequality in QALE. CONCLUSIONS LB-first to inform first-line aNSCLC therapy can improve health outcomes. With current diagnostic performance, the benefit is the greatest among Asian patients, thereby potentially widening racial and ethnic differences in survival among patients with aNSCLC. Assuming equally distributed opportunity costs and access, LB-first does not worsen and, in fact, may reduce inequality in general population health according to race and ethnicity.
Collapse
Affiliation(s)
- Jeroen P Jansen
- Department of Clinical Pharmacy, UCSF Center for Translational and Policy Research on Precision Medicine (TRANSPERS), San Francisco, CA, USA; UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA; UCSF Philip R. Lee Institute for Health Policy, San Francisco, CA, USA.
| | - Meera V Ragavan
- Division of Hematology and Oncology, UCSF Department of Medicine, San Francisco, CA, USA
| | - Cheng Chen
- Department of Clinical Pharmacy, UCSF Center for Translational and Policy Research on Precision Medicine (TRANSPERS), San Francisco, CA, USA
| | - Michael P Douglas
- Department of Clinical Pharmacy, UCSF Center for Translational and Policy Research on Precision Medicine (TRANSPERS), San Francisco, CA, USA
| | - Kathryn A Phillips
- Department of Clinical Pharmacy, UCSF Center for Translational and Policy Research on Precision Medicine (TRANSPERS), San Francisco, CA, USA; UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA; UCSF Philip R. Lee Institute for Health Policy, San Francisco, CA, USA
| |
Collapse
|
2
|
Chen C, Douglas MP, Ragavan MV, Phillips KA, Jansen JP. Clinical validity and utility of circulating tumor DNA (ctDNA) testing in advanced non-small cell lung cancer (aNSCLC): a systematic literature review and meta-analysis. medRxiv 2023:2023.10.27.23297657. [PMID: 37961510 PMCID: PMC10635208 DOI: 10.1101/2023.10.27.23297657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Purpose Circulating tumor DNA (ctDNA) testing has become a promising tool to guide first-line (1L) targeted treatment for advanced non-small cell lung cancer (aNSCLC). This study aims to estimate the clinical validity (CV) and clinical utility (CU) of ctDNA-based next-generation sequencing (NGS) for oncogenic driver mutations to inform 1L treatment decisions in aNSCLC through a systematic literature review and meta-analysis. Methods A systematic literature search was conducted in PubMed/MEDLINE and Embase to identify randomized control trials or observational studies reporting CV/CU on ctDNA testing in patients with aNSCLC. Meta-analyses were performed using bivariate random-effects models to estimate pooled sensitivity and specificity. Progression-free/overall survival (PFS/OS) was summarized for CU studies. Results Eighteen studies were identified: 17 CV only, 2 CU only, and 1 both. Thirteen studies were included for the meta-analysis on multi-gene detection. The overall sensitivity and specificity for ctDNA detection of any mutation were 0.69 (95% CI, 0.63-0.74) and 0.99 (95% CI, 0.97-1.00) respectively. However, sensitivity varied greatly by driver gene, ranging from 0.29 (95% CI, 0.13-0.53) for ROS 1 to 0.77 (95% CI, 0.63-0.86) for KRAS . Two studies compared PFS with ctDNA versus tissue-based testing followed by 1L targeted therapy found no significant differences. One study reported OS curves on ctDNA-matched and tissue-matched therapies but no hazard ratios were provided. Conclusion ctDNA testing demonstrated an overall acceptable diagnostic accuracy in aNSCLC patients, however, sensitivity varied greatly by driver mutation. Further research is needed, especially for uncommon driver mutations, to better understand the CU of ctDNA testing in guiding targeted treatments for aNSCLC.
Collapse
|
3
|
Douglas MP, Ragavan MV, Chen C, Kumar A, Gray SW, Blakely CM, Phillips KA. Private Payer and Medicare Coverage Policies for Use of Circulating Tumor DNA Tests in Cancer Diagnostics and Treatment. J Natl Compr Canc Netw 2023; 21:609-616.e4. [PMID: 37308126 PMCID: PMC10846388 DOI: 10.6004/jnccn.2023.7011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 02/07/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Circulating tumor DNA (ctDNA) is used to select initial targeted therapy, identify mechanisms of therapeutic resistance, and measure minimal residual disease (MRD) after treatment. Our objective was to review private and Medicare coverage policies for ctDNA testing. METHODS Policy Reporter was used to identify coverage policies (as of February 2022) from private payers and Medicare Local Coverage Determinations (LCDs) for ctDNA tests. We abstracted data regarding policy existence, ctDNA test coverage, cancer types covered, and clinical indications. Descriptive analyses were performed by payer, clinical indication, and cancer type. RESULTS A total of 71 of 1,066 total policies met study inclusion criteria, of which 57 were private policies and 14 were Medicare LCDs; 70% of private policies and 100% of Medicare LCDs covered at least one indication. Among 57 private policies, 89% specified a policy for at least 1 clinical indication, with coverage for ctDNA for initial treatment selection most common (69%). Of 40 policies addressing progression, coverage was provided 28% of the time, and of 20 policies addressing MRD, coverage was provided 65% of the time. Non-small cell lung cancer (NSCLC) was the cancer type most frequently covered for initial treatment (47%) and progression (60%). Among policies with ctDNA coverage, coverage was restricted to patients without available tissue or in whom biopsy was contraindicated in 91% of policies. MRD was commonly covered for hematologic malignancies (30%) and NSCLC (25%). Of the 14 Medicare LCD policies, 64% provided coverage for initial treatment selection and progression, and 36% for MRD. CONCLUSIONS Some private payers and Medicare LCDs provide coverage for ctDNA testing. Private payers frequently cover testing for initial treatment, especially for NSCLC, when tissue is insufficient or biopsy is contraindicated. Coverage remains variable across payers, clinical indications, and cancer types despite inclusion in clinical guidelines, which could impact delivery of effective cancer care.
Collapse
Affiliation(s)
- Michael P. Douglas
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California
| | - Meera V. Ragavan
- Division of Hematology/Oncology, University of California San Francisco, San Francisco, California
| | - Cheng Chen
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California
- Department of Clinical Pharmacy, UCSF Center for Translational and Policy Research on Precision Medicine (TRANSPERS), San Francisco, California
| | - Anika Kumar
- UCSF School of Medicine, San Francisco, California
| | - Stacy W. Gray
- Department of Population Science, City of Hope, Duarte, California
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California
| | - Collin M. Blakely
- Division of Hematology/Oncology, University of California San Francisco, San Francisco, California
- UCSF Thoracic Oncology Program, University of California San Francisco, San Francisco, California
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Kathryn A. Phillips
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California
- Department of Clinical Pharmacy, UCSF Center for Translational and Policy Research on Precision Medicine (TRANSPERS), San Francisco, California
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
- UCSF Philip R. Lee Institute for Health Policy, San Francisco, California
| |
Collapse
|
4
|
Williamson KM, Butler M, Elton B, Taylor J, Islam F, Douglas MP, Kirk MD, Durrheim DN. Transmission of SARS-CoV-2 Delta variant from an infected aircrew member on a short-haul domestic flight, Australia 2021. J Travel Med 2022; 29:6854865. [PMID: 36448584 PMCID: PMC9793396 DOI: 10.1093/jtm/taac144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 11/17/2022] [Accepted: 11/20/2022] [Indexed: 12/05/2022]
Abstract
In June 2021, when COVID-19 incidence in Australia was low, a COVID-19 (Delta variant) cluster occurred on an 81-minute domestic flight, with an aircrew member as the likely source. Outbreak investigation demonstrated that SARS-CoV-2 may be transmitted during short-haul flights and that mask use protected against infection.
Collapse
Affiliation(s)
- Kirsten M Williamson
- Hunter New England Population Health, Hunter New England Local Health District, Newcastle, NSW 2305, Australia
| | - Michelle Butler
- Hunter New England Population Health, Hunter New England Local Health District, Newcastle, NSW 2305, Australia
| | - Benjamin Elton
- Hunter New England Population Health, Hunter New England Local Health District, Newcastle, NSW 2305, Australia
| | - Joanne Taylor
- Hunter New England Population Health, Hunter New England Local Health District, Newcastle, NSW 2305, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW 2308, Australia
| | - Fakhrul Islam
- Hunter New England Population Health, Hunter New England Local Health District, Newcastle, NSW 2305, Australia
| | - Michael P Douglas
- Public Health Response Branch, New South Wales Ministry of Health, Sydney, NSW 2060, Australia.,School of Medicine, University of Western Sydney, NSW 2052, Australia
| | - Martyn D Kirk
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT 2601, Australia
| | - David N Durrheim
- Hunter New England Population Health, Hunter New England Local Health District, Newcastle, NSW 2305, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW 2308, Australia
| |
Collapse
|
5
|
Weldon CB, Trosman JR, Liang SY, Douglas MP, Scheuner MT, Kurian A, Schaa KL, Roscow B, Erwin D, Phillips KA. Genetic counselors' experience with reimbursement and patient out-of-pocket cost for multi-cancer gene panel testing for hereditary cancer syndromes. J Genet Couns 2022; 31:1394-1403. [PMID: 35900261 PMCID: PMC9722528 DOI: 10.1002/jgc4.1614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 06/15/2022] [Accepted: 06/21/2022] [Indexed: 12/14/2022]
Abstract
Multi-cancer gene panels for hereditary cancer syndromes (hereditary cancer panels, HCPs) are widely available, and some laboratories have programs that limit patients' out-of-pocket (OOP) cost share. However, little is known about practices by cancer genetic counselors for discussing and ordering an HCP and how insurance reimbursement and patient out-of-pocket share impact these practices. We conducted a survey of cancer genetic counselors based in the United States through the National Society of Genetic Counselors to assess the impact of reimbursement and patient OOP share on ordering of an HCP and hereditary cancer genetic counseling. Data analyses were conducted using chi-square and t tests. We received 135 responses (16% response rate). We found that the vast majority of respondents (94%, 127/135) ordered an HCP for patients rather than single-gene tests to assess hereditary cancer predisposition. Two-thirds of respondents reported that their institution had no protocol related to discussing HCPs with patients. Most respondents (84%, 114/135) indicated clinical indications and patients' requests as important in selecting and ordering HCPs, while 42%, 57/135, considered reimbursement and patient OOP share factors important. We found statistically significant differences in reporting of insurance as a frequently used payment method for HCPs and in-person genetic counseling (84% versus 59%, respectively, p < 0.0001). Perceived patient willingness to pay more than $100 was significantly higher for HCPs than for genetic counseling(41% versus 22%, respectively, p < 0.01). In sum, genetic counselors' widespread selection and ordering of HCPs is driven more by clinical indications and patient preferences than payment considerations. Respondents perceived that testing is more often reimbursed by insurance than genetic counseling, and patients are more willing to pay for an HCP than for genetic counseling. Policy efforts should address this incongruence in reimbursement and patient OOP share. Patient-centered communication should educate patients on the benefit of genetic counseling.
Collapse
Affiliation(s)
| | - Julia R. Trosman
- Center for Business Models in Healthcare, Glencoe, IL, USA
- Department of Clinical Pharmacy; Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California-San Francisco, San Francisco, CA, USA
| | - Su-Ying Liang
- Sutter Health-Palo Alto Medical Foundation Research Institute, Palo Alto, CA
| | - Michael P. Douglas
- Department of Clinical Pharmacy; Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California-San Francisco, San Francisco, CA, USA
| | - Maren T. Scheuner
- Departments of Medicine and Pediatrics, School of Medicine, University of California, San Francisco, CA, USA
- San Francisco VA Health Care System, San Francisco, CA, USA
| | - Allison Kurian
- Departments of Medicine and of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
| | - Kendra L. Schaa
- Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Breanna Roscow
- Oncology Regional Medical Specialists Department, Myriad Genetics, Inc, Salt Lake City, UT
| | - Deanna Erwin
- Genetic Counseling Services, Color Health, Burlingame, CA
| | - Kathryn A. Phillips
- Department of Clinical Pharmacy; Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California-San Francisco, San Francisco, CA, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| |
Collapse
|
6
|
Arias JJ, Lin GA, Tyler AM, Douglas MP, Phillips KA. Geriatricians’ Perspectives on the Multiple Dimensions of Utility of Genetic Testing for Alzheimer’s Disease: A Qualitative Study. J Alzheimers Dis 2022; 90:1011-1019. [DOI: 10.3233/jad-220674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background: Research advancements in Alzheimer’s disease (AD) raise opportunities for genetic testing to improve diagnostic and risk assessment. Despite emerging developments, it is unclear how geriatricians perceive the potential clinical and personal utility of genetic testing for their patients. Geriatricians’ perspectives are essential to understanding potential ethical, policy, and clinical challenges. Objective: In this paper, we report on geriatricians’ perspectives on the utility of genetic testing for AD. Methods: Semi-structured interviews with California geriatricians within different practices settings to collect and characterize their perspectives on genetic testing for AD. We used an adapted grounded theory approach to analyze recorded and transcribed interviews. Results: We identified geriatricians’ (n = 10) perspectives on the clinical and personal utility of testing, alongside their views on clinical care approaches for older adults. Geriatricians perceived minimal clinical utility of genetic testing for AD, though that may change with the availability of disease-modifying therapies. Yet, they recognized the potential personal utility of testing (e.g., assisting with future financial planning). Finally, geriatricians expressed concerns regarding patients’ anxiety from learning about genetic status, particularly through direct-to-consumer (DTC) testing. Conclusion: Our data highlight that the decision to order genetic testing requires clinical and ethical considerations, including balancing limited clinical utility with the potential personal utility. Although DTC testing is available, geriatricians perceive that they have an important role in managing the decision to test and interpreting the results. Further research is needed to inform policy and ethical guidelines to support geriatricians’ critical role to counsel patients considering clinical and DTC genetic testing.
Collapse
Affiliation(s)
- Jalayne J. Arias
- School of Public Health, Georgia State University, Atlanta, GA, USA
| | - Grace A. Lin
- Department of Internal Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Ana M. Tyler
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Michael P. Douglas
- Center for Translational and Policy Research on Personalized Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Kathryn A. Phillips
- Center for Translational and Policy Research on Personalized Medicine, University of California, San Francisco, San Francisco, CA, USA
| |
Collapse
|
7
|
Douglas MP, Kumar A. Analyzing Precision Medicine Utilization with Real-World Data: A Scoping Review. J Pers Med 2022; 12:jpm12040557. [PMID: 35455673 PMCID: PMC9025578 DOI: 10.3390/jpm12040557] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/25/2022] [Accepted: 03/29/2022] [Indexed: 11/16/2022] Open
Abstract
Precision medicine (PM), specifically genetic-based testing, is currently used in over 140,000 individual tests to inform the clinical management of disease. Though several databases (e.g., the NIH Genetic Testing Registry) demonstrate the availability of these sequencing-based tests, we do not currently understand the extent to which these tests are used. There exists a need to synthesize the body of real-world data (RWD) describing the use of sequencing-based tests to inform their appropriate use. To accomplish this, we performed a scoping review to examine what RWD sources have been used in studies of PM utilization between January 2015 and August 2021 to characterize the use of genome sequencing (GS), exome sequencing (ES), tumor sequencing (TS), next-generation sequencing-based panels (NGS), gene expression profiling (GEP), and pharmacogenomics (PGx) panels. We abstracted variables describing the use of these types of tests and performed a descriptive statistical analysis. We identified 440 articles in our search and included 72 articles in our study. Publications based on registry databases were the most common, followed by studies based on private insurer administrative claims. Slightly more than one-third (38%) used integrated datasets. Two thirds (67%) of the studies focused on the use of tests for oncological clinical applications. We summarize the RWD sources used in peer-reviewed literature on the use of PM. Our findings will help improve future study design by encouraging the use of centralized databases and registries to track the implementation and use of PM.
Collapse
Affiliation(s)
- Michael P. Douglas
- Center for Translational and Policy Research on Precision Medicine (TRANSPERS), Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, CA 94143, USA
- Correspondence: ; Tel.: +1-415-502-4025
| | - Anika Kumar
- School of Medicine, University of California, San Francisco, San Francisco, CA 94143, USA;
| |
Collapse
|
8
|
Deverka PA, Douglas MP, Phillips KA. Multicancer Screening Tests: Anticipating And Addressing Considerations For Payer Coverage And Patient Access. Health Aff (Millwood) 2022; 41:383-389. [PMID: 35254936 DOI: 10.1377/hlthaff.2021.01316] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There is a tremendous public health need to identify potentially lethal cancers at earlier stages, when there is a greater chance for improved survival. Although in the US there are currently screening recommendations for only five cancers (breast, colorectal, cervical, lung, and prostate), new tests can screen for up to fifty cancers simultaneously based on a simple blood draw. However, these multicancer screening tests (also called "liquid biopsy" tests) will also present challenges to payers because of intrinsic features of the tests and the complexity of payer coverage assessments for screening tests. We describe these considerations while also offering potential solutions that can inform payers' decision making if these tests prove to be beneficial.
Collapse
Affiliation(s)
- Patricia A Deverka
- Patricia A. Deverka , University of California San Francisco, San Francisco, California
| | | | | |
Collapse
|
9
|
Douglas MP, Lin GA, Trosman JR, Phillips KA. Hereditary cancer panel testing challenges and solutions for the latinx community: costs, access, and variants. J Community Genet 2022; 13:75-80. [PMID: 34743282 PMCID: PMC8799811 DOI: 10.1007/s12687-021-00563-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 10/28/2021] [Indexed: 11/29/2022] Open
Abstract
Hereditary breast and ovarian cancers (HBOCs) are common among the Latinx population, and risk testing is recommended using multi-gene hereditary cancer panels (HCPs). However, little is known about how payer reimbursement and out-of-pocket expenses impact provider ordering of HCP in the Latinx population. Our objective is to describe key challenges and possible solutions for HCP testing in the Latinx population. As part of a larger study, we conducted semi-structured interviews with key provider informants (genetic counselors, oncologist, nurse practitioner) from safety-net institutions in the San Francisco Bay Area. We used a deductive thematic analysis approach to summarize themes around challenges and possible solutions to facilitating HCP testing in Latinx patients. We found few financial barriers for HCP testing for the Latinx population due to laboratory patient assistance programs that cover testing at low or no cost to patients. However, we found potential challenges related to the sustainability of low-cost testing and out-of-pocket expenses for patients, access to cascade testing for family members, and pathogenic variants specific to Latinx. Providers questioned whether current laboratory payment programs that decrease barriers to testing are sustainable and suggested solutions for accessing cascade testing and ensuring variants specific to the Latinx population were included in testing. The use of laboratories with payment assistance programs reduces barriers to HCP testing among the US population; however, other barriers are present that may impact testing use in the Latinx population and must be addressed to ensure equitable access to HCP testing for this population.
Collapse
Affiliation(s)
- Michael P Douglas
- UCSF Center for Translational and Policy Research On Personalized Medicine (TRANSPERS), Department of Clinical Pharmacy, University of California San Francisco, 490 Illinois Street, 3rd Floor, Box 0613, San Francisco, CA, 94143, USA.
| | - Grace A Lin
- UCSF Center for Translational and Policy Research On Personalized Medicine (TRANSPERS), Department of Clinical Pharmacy, University of California San Francisco, 490 Illinois Street, 3rd Floor, Box 0613, San Francisco, CA, 94143, USA
- Department of Medicine, University of California, San Francisco, CA, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
| | - Julia R Trosman
- UCSF Center for Translational and Policy Research On Personalized Medicine (TRANSPERS), Department of Clinical Pharmacy, University of California San Francisco, 490 Illinois Street, 3rd Floor, Box 0613, San Francisco, CA, 94143, USA
- Center for Business Models in Healthcare, Glencoe, IL, USA
| | - Kathryn A Phillips
- UCSF Center for Translational and Policy Research On Personalized Medicine (TRANSPERS), Department of Clinical Pharmacy, University of California San Francisco, 490 Illinois Street, 3rd Floor, Box 0613, San Francisco, CA, 94143, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California-San Francisco, San Francisco, CA, USA
| |
Collapse
|
10
|
Weldon CB, Liang SY, Phillips KA, Douglas MP, Scheuner MT, Kurian AW, Schaa K, Roscow B, Erwin D, Trosman JR. Multicancer hereditary syndrome testing: Genetic counselors’ perspectives. J Clin Oncol 2021. [DOI: 10.1200/jco.2020.39.28_suppl.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
106 Background: The accessibility of cancer hereditary syndrome testing has increased, and the cost has declined significantly in the past few years. We conducted a national, quantitative survey of genetic counselors (GCs) to assess their perspectives on what influences hereditary cancer genetic testing decisions and practices, with a focus on cost. This survey was funded by NIH, conducted by UCSF TRANSPERS, and supported by the National Society of Genetic Counselors(NSGC). Methods: The survey was developed through literature review, expert interviews, and a pilot. Sent to the NSGC Cancer Special Interest Group via email. Chi-square tests were used to examine variability. Results: The survey response rate was 56% (202/363). Multiple hereditary cancer syndrome tests are discussed often/always by 86% of genetic counselors (GCs).The existence of an institutional protocol on multiple hereditary cancer syndrome testing was reported by 35.4% of GCs. When asked about GC counseling encounters, GCs report insurance rarely/never pays for: 25.2% pre-test in-person,39.7% for pre-test tele-genetics, 35.4% post-test in-person, and 52.9% post-test tele-genetics. GCs rated clinical factors higher than cost as influencing decision for multiple hereditary syndrome cancer testing (table); the total cost of the test was least important. These patterns were similar across the GCs institution types and years in practice. Conclusions: We found consistent use of multiple hereditary cancer syndrome tests, with less focus on cost, out-of-pocket, and insurance coverage and more of a focus on clinical indicators. GCs reported challenges with reimbursement for GC counseling encounters. The shift toward more genetic counseling encounters via tele-genetics necessitates evaluation of insurance reimbursement.[Table: see text]
Collapse
Affiliation(s)
| | - Su-Ying Liang
- Sutter Health-Palo Alto Medical Foundation Research Institute, Palo Alto, CA
| | - Kathryn A. Phillips
- Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California, San Francisco, San Francisco, CA
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Scheuner MT, Douglas MP, Sales P, Ackerman SL, Phillips KA. Laboratory business models and practices: implications for availability and access to germline genetic testing. Genet Med 2021; 23:1681-1688. [PMID: 33958748 PMCID: PMC8460432 DOI: 10.1038/s41436-021-01184-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 04/09/2021] [Accepted: 04/09/2021] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Germline testing laboratories have evolved over several decades. We describe laboratory business models and practices and explore their implications on germline testing availability and access. METHODS We conducted semistructured interviews with key informants using purposive sampling. We interviewed 13 key informants representing 14 laboratories. We used triangulation and iterative data analysis to identify topics concerning laboratory business models and practices. RESULTS We characterized laboratories as full-service (FSL), for-profit germline (PGL), and not-for-profit germline (NGL). Relying on existing payer contracts is a key characteristic of the FSL business models. FSLs focus on high-volume germline tests with evidence of clinical utility that have reimbursable codes. In comparison, a key business model characteristic of PGLs is direct patient billing facilitated by commodity-based pricing made possible by investors and industry partnerships. Client billing is a key business model characteristic of NGLs. Because many NGLs exist within academic settings, they are challenged by their inability to optimize laboratory processes and billing practices. CONCLUSION Continued availability of, and access to germline testing will depend on the financial success of laboratories; organizational characteristics of laboratories and payers; cultural factors, particularly consumer interest and trust; and societal factors, such as regulation and laws surrounding pricing and reimbursement.
Collapse
Affiliation(s)
- Maren T Scheuner
- Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), Department of Clinical Pharmacy, University of California-San Francisco, San Francisco, CA, USA.
- Department of Medicine, Division of Hematology-Oncology and Department of Pediatrics, Division of Medical Genetics, University of California-San Francisco, School of Medicine, San Francisco, CA, USA.
- San Francisco VA Health Care System, San Francisco, CA, USA.
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California-San Francisco, San Francisco, CA, USA.
| | - Michael P Douglas
- Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), Department of Clinical Pharmacy, University of California-San Francisco, San Francisco, CA, USA
| | - Paloma Sales
- San Francisco VA Health Care System, San Francisco, CA, USA
- Northern California Institute for Research and Education, San Francisco, CA, USA
| | - Sara L Ackerman
- Department of Social and Behavioral Sciences, University of California-San Francisco, San Francisco, CA, USA
| | - Kathryn A Phillips
- Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), Department of Clinical Pharmacy, University of California-San Francisco, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, University of California-San Francisco, San Francisco, CA, USA
- Philip R. Lee Institute for Health Policy Studies, University of California-San Francisco, San Francisco, CA, USA
| |
Collapse
|
12
|
Lin GA, Trosman JR, Douglas MP, Weldon CB, Scheuner MT, Kurian A, Phillips KA. Influence of payer coverage and out-of-pocket costs on ordering of NGS panel tests for hereditary cancer in diverse settings. J Genet Couns 2021; 31:130-139. [PMID: 34231930 DOI: 10.1002/jgc4.1459] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/27/2021] [Accepted: 05/30/2021] [Indexed: 11/06/2022]
Abstract
The landscape of payment for genetic testing has been changing, with an increase in the number of laboratories offering testing, larger panel offerings, and lower prices. To determine the influence of payer coverage and out-of-pocket costs on the ordering of NGS panel tests for hereditary cancer in diverse settings, we conducted semi-structured interviews with providers who conduct genetic counseling and order next-generation sequencing (NGS) panels purposefully recruited from 11 safety-net clinics and academic medical centers (AMCs) in California and North Carolina, states with diverse populations and divergent Medicaid expansion policies. Thematic analysis was done to identify themes related to the impact of reimbursement and out-of-pocket expenses on test ordering. Specific focus was put on differences between settings. Respondents from both safety-net clinics and AMCs reported that they are increasingly ordering panels instead of single-gene tests, and tests were ordered primarily from a few commercial laboratories. Surprisingly, safety-net clinics reported few barriers to testing related to cost, largely due to laboratory assistance with prior authorization requests and patient payment assistance programs that result in little to no patient out-of-pocket expenses. AMCs reported greater challenges navigating insurance issues, particularly prior authorization. Both groups cited non-coverage of genetic counseling as a major barrier to testing. Difficulty of access to cascade testing, particularly for family members that do not live in the United States, was also of concern. Long-term sustainability of laboratory payment assistance programs was a major concern; safety-net clinics were particularly concerned about access to testing without such programs. There were few differences between states. In conclusion, the use of laboratories with payment assistance programs reduces barriers to NGS panel testing among diverse populations. Such programs represent a major change to the financing and affordability of genetic testing. However, access to genetic counseling is a barrier and must be addressed to ensure equity in testing.
Collapse
Affiliation(s)
- Grace A Lin
- Department of Medicine, University of California, San Francisco, CA, USA.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA.,Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California-San Francisco, San Francisco, CA, USA
| | - Julia R Trosman
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California-San Francisco, San Francisco, CA, USA.,Center for Business Models in Healthcare, Glencoe, IL, USA
| | - Michael P Douglas
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California-San Francisco, San Francisco, CA, USA
| | | | - Maren T Scheuner
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA.,Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California-San Francisco, San Francisco, CA, USA.,UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Allison Kurian
- Departments of Medicine and of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
| | - Kathryn A Phillips
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA.,Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California-San Francisco, San Francisco, CA, USA.,UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| |
Collapse
|
13
|
Phillips KA, Douglas MP, Wordsworth S, Buchanan J, Marshall DA. Availability and funding of clinical genomic sequencing globally. BMJ Glob Health 2021; 6:bmjgh-2020-004415. [PMID: 33574068 PMCID: PMC7880109 DOI: 10.1136/bmjgh-2020-004415] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 01/06/2023] Open
Abstract
The emergence of next-generation genomic sequencing (NGS) tests for use in clinical care has generated widespread interest around the globe, but little is known about the availability and funding of these tests worldwide. We examined NGS availability across world regions and countries, with a particular focus on availability of three key NGS tests—Whole-Exome Sequencing or Whole-Genome Sequencing for diagnosis of suspected genetic diseases such as intellectual disability disorders or rare diseases, non-invasive prenatal testing for common genetic abnormalities in fetuses and tumor sequencing for therapy selection and monitoring of cancer treatment. We found that these NGS tests are available or becoming available in every major region of the world. This includes both high-income countries with robust genomic programmes such as the USA and the UK, and growing availability in countries with upper-middle-income economies. We used exploratory case studies across three diverse health care systems (publicly funded/national (UK), publicly funded/provincial (Canada) and mixed private/public system (USA)) to illustrate the funding challenges and approaches used to address those challenges that might be adopted by other countries. We conclude by assessing what type of data and initiatives will be needed to better track and understand the use of NGS around the world as such testing continues to expand.
Collapse
Affiliation(s)
- Kathryn A Phillips
- UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS); Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California, USA
| | - Michael P Douglas
- UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS); Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California, USA
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, Oxfordshire, UK
| | - James Buchanan
- Health Economics Research Centre, Nuffield Department of Population Health, National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, Oxfordshire, UK
| | - Deborah A Marshall
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
14
|
Weldon CB, Liang SY, Phillips KA, Douglas MP, Scheuner MT, Kurian AW, Schaa K, Roscow B, Erwin D, Trosman JR. Multicancer hereditary syndrome testing: Genetic counselors’ perspectives. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.10594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10594 Background: The accessibility of cancer hereditary syndrome testing has increased, and the cost has declined significantly in the past few years. We conducted a national, quantitative survey of genetic counselors (GCs) to assess their perspectives on what influences hereditary cancer genetic testing decisions and practices, with a focus on cost. This survey was funded by NIH, conducted by UCSF TRANSPERS, and supported by the National Society of Genetic Counselors (NSGC). Methods: The survey was developed through literature review, expert interviews, and a pilot. Sent to the NSGC Cancer Special Interest Group via email. Chi-square tests were used to examine variability. Results: The survey response rate was 56% (202/363). Multiple hereditary cancer syndrome tests are discussed often/always by 86% of genetic counselors (GCs). The existence of an institutional protocol on multiple hereditary cancer syndrome testing was reported by 35.4% of GCs. When asked about GC counseling encounters, GCs report insurance rarely/never pays for: 25.2% pre-test in-person, 39.7% for pre-test tele-genetics, 35.4% post-test in-person, and 52.9% post-test tele-genetics. GCs rated clinical factors higher than cost as influencing decision for multiple hereditary syndrome cancer testing (table); the total cost of the test was least important. These patterns were similar across the GCs institution types and years in practice. Conclusions: We found consistent use of multiple hereditary cancer syndrome tests, with less focus on cost, out-of-pocket, and insurance coverage and more of a focus on clinical indicators. GCs reported challenges with reimbursement for GC counseling encounters. The shift toward more genetic counseling encounters via tele-genetics necessitates evaluation of insurance reimbursement.[Table: see text]
Collapse
Affiliation(s)
| | - Su-Ying Liang
- Sutter Health-Palo Alto Medical Foundation Research Institute, Palo Alto, CA
| | - Kathryn A Phillips
- Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California, San Francisco, San Francisco, CA
| | | | | | | | | | | | | | | |
Collapse
|
15
|
Arias JJ, Tyler AM, Douglas MP, Phillips KA. Private payer coverage policies for ApoE-e4 genetic testing. Genet Med 2021; 23:614-620. [PMID: 33420342 PMCID: PMC8035237 DOI: 10.1038/s41436-020-01042-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE ApoE-e4 has a well-established connection to late-onset Alzheimer disease (AD) and is available clinically. Yet, there have been no analyses of payer coverage policies for ApoE. Our objective was to analyze private payer coverage policies for ApoE genetic testing, examine the rationales, and describe supporting evidence referenced by policies. METHODS We searched for policies from the eight largest private payers (by member numbers) covering ApoE testing for late-onset AD. We implemented content analysis methods to evaluate policies for coverage decisions and rationales. RESULTS Seven payers had policies with positions on ApoE testing. Five explicitly state they do not cover ApoE and two apply generic preauthorization criteria. Rationales supporting coverage decisions include: reference to guidelines or national standards, inadequate data supporting testing, characterizing testing as investigational, or that testing would not alter patients' clinical management. CONCLUSION Seven of the eight largest private payers' coverage policies reflect standards that discourage ApoE testing due to a lack of clinical utility. As the field advances, ApoE testing may have an important clinical role, particularly considering that disease-modifying therapies are under evaluation by the US Food and Drug Administration. These types of field advancements may not be consistent with private payers' policies and may cause payers to reevaluate existing coverage policies.
Collapse
Affiliation(s)
- Jalayne J Arias
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA.
| | - Ana M Tyler
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Michael P Douglas
- Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California, San Francisco, San Francisco, CA, USA
| | - Kathryn A Phillips
- Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California, San Francisco, San Francisco, CA, USA
| |
Collapse
|
16
|
Affiliation(s)
- Kathryn A Phillips
- Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), Department of Clinical Pharmacy, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Michael P Douglas
- Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), Department of Clinical Pharmacy, University of California, San Francisco
| | - Deborah A Marshall
- Cumming School of Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
17
|
Douglas MP, Gray SW, Phillips KA. Private Payer and Medicare Coverage for Circulating Tumor DNA Testing: A Historical Analysis of Coverage Policies From 2015 to 2019. J Natl Compr Canc Netw 2020; 18:866-872. [PMID: 32634780 DOI: 10.6004/jnccn.2020.7542] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/29/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Clinical adoption of the sequencing of circulating tumor DNA (ctDNA) for cancer has rapidly increased in recent years. This sequencing is used to select targeted therapy and monitor nonresponding or progressive tumors to identify mechanisms of therapeutic resistance. Our study objective was to review available coverage policies for cancer ctDNA-based testing panels to examine trends from 2015 to 2019. METHODS We analyzed publicly available private payer policies and Medicare national coverage determinations and local coverage determinations (LCDs) for ctDNA-based panel tests for cancer. We coded variables for each year representing policy existence, covered clinical scenario, and specific ctDNA test covered. Descriptive analyses were performed. RESULTS We found that 38% of private payer coverage policies provided coverage of ctDNA-based panel testing as of July 2019. Most private payer policy coverage was highly specific: 87% for non-small cell lung cancer, 47% for EGFR gene testing, and 79% for specific brand-name tests. There were 8 final, 2 draft, and 2 future effective final LCDs (February 3 and March 15, 2020) that covered non-FDA-approved ctDNA-based tests. The draft and future effective LCDs were the first policies to cover pan-cancer use. CONCLUSIONS Coverage of ctDNA-based panel testing for cancer indications increased from 2015 to 2019. The trend in private payer and Medicare coverage is an increasing number of coverage policies, number of positive policies, and scope of coverage. We found that Medicare coverage policies are evolving to pan-cancer uses, signifying a significant shift in coverage frameworks. Given that genomic medicine is rapidly changing, payers and policymakers (eg, guideline developers) will need to continue to evolve policies to keep pace with emerging science and standards in clinical care.
Collapse
Affiliation(s)
- Michael P Douglas
- 1Department of Clinical Pharmacy, UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), San Francisco
| | - Stacy W Gray
- 2Department of Population Science, and.,3Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte; and
| | - Kathryn A Phillips
- 1Department of Clinical Pharmacy, UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), San Francisco.,4UCSF Philip R. Lee Institute for Health Policy, and.,5UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| |
Collapse
|
18
|
Trosman JR, Douglas MP, Liang SY, Weldon CB, Kurian AW, Kelley RK, Phillips KA. Insights From a Temporal Assessment of Increases in US Private Payer Coverage of Tumor Sequencing From 2015 to 2019. Value Health 2020; 23:551-558. [PMID: 32389219 PMCID: PMC7217867 DOI: 10.1016/j.jval.2020.01.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/09/2019] [Accepted: 01/08/2020] [Indexed: 05/12/2023]
Abstract
OBJECTIVES To examine the temporal trajectory of insurance coverage for next-generation tumor sequencing (sequencing) by private US payers, describe the characteristics of coverage adopters and nonadopters, and explore adoption trends relative to the Centers for Medicare and Medicaid Services' National Coverage Determination (CMS NCD) for sequencing. METHODS We identified payers with positive coverage (adopters) or negative coverage (nonadopters) of sequencing on or before April 1, 2019, and abstracted their characteristics including size, membership in the BlueCross BlueShield Association, and whether they used a third-party policy. Using descriptive statistics, payer characteristics were compared between adopters and nonadopters and between pre-NCD and post-NCD adopters. An adoption timeline was constructed. RESULTS Sixty-nine payers had a sequencing policy. Positive coverage started November 30, 2015, with 1 payer and increased to 33 (48%) as of April 1, 2019. Adopters were less likely to be BlueCross BlueShield members (P < .05) and more likely to use a third-party policy (P < .001). Fifty-eight percent of adopters were small payers. Among adopters, 52% initiated coverage pre-NCD over a 25-month period and 48% post-NCD over 17 months. CONCLUSIONS We found an increase, but continued variability, in coverage over 3.5 years. Temporal analyses revealed important trends: the possible contribution of the CMS NCD to a faster pace of coverage adoption, the interdependence in coverage timing among BlueCross BlueShield members, the impact of using a third-party policy on coverage timing, and the importance of small payers in early adoption. Our study is a step toward systematic temporal research of coverage for precision medicine, which will inform policy and affordability assessments.
Collapse
Affiliation(s)
- Julia R Trosman
- Center for Translational and Policy Research on Personalized Medicine, University of California at San Francisco, San Francisco, CA, USA; Center for Business Models in Healthcare, Chicago, IL, USA.
| | - Michael P Douglas
- Center for Translational and Policy Research on Personalized Medicine, University of California at San Francisco, San Francisco, CA, USA
| | - Su-Ying Liang
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
| | - Christine B Weldon
- Center for Translational and Policy Research on Personalized Medicine, University of California at San Francisco, San Francisco, CA, USA; Center for Business Models in Healthcare, Chicago, IL, USA
| | - Allison W Kurian
- Departments of Medicine & of Health Research & Policy, Stanford University, Palo Alto, CA, USA
| | - Robin K Kelley
- Philip R. Lee Institute for Health Policy, University of California, San Francisco, San Francisco, CA, USA
| | - Kathryn A Phillips
- Center for Translational and Policy Research on Personalized Medicine, University of California at San Francisco, San Francisco, CA, USA; Philip R. Lee Institute for Health Policy, University of California, San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California at San Francisco, San Francisco, CA, USA
| |
Collapse
|
19
|
Deverka PA, Douglas MP, Phillips KA. Use of Real-World Evidence in US Payer Coverage Decision-Making for Next-Generation Sequencing-Based Tests: Challenges, Opportunities, and Potential Solutions. Value Health 2020; 23:540-550. [PMID: 32389218 PMCID: PMC7219085 DOI: 10.1016/j.jval.2020.02.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 01/26/2020] [Accepted: 02/02/2020] [Indexed: 05/05/2023]
Abstract
OBJECTIVES Given the potential of real-world evidence (RWE) to inform understanding of the risk-benefit profile of next-generation sequencing (NGS)-based testing, we undertook a study to describe the current landscape of whether and how payers use RWE as part of their coverage decision making and potential solutions for overcoming barriers. METHODS We performed a scoping literature review of existing RWE evidentiary frameworks for evaluating new technologies and identified barriers to clinical integration and evidence gaps for NGS. We synthesized findings as potential solutions for improving the relevance and utility of RWE for payer decision-making. RESULTS Payers require evidence of clinical utility to inform coverage decisions, yet we found a relatively small number of published RWE studies, and these are predominately focused on oncology, pharmacogenomics, and perinatal/pediatric testing. We identified 3 categories of innovation that may help address the current undersupply of RWE studies for NGS: (1) increasing use of RWE to inform outcomes-based contracting for new technologies, (2) precision medicine initiatives that integrate clinical and genomic data and enable data sharing, and (3) Food and Drug Administration reforms to encourage the use of RWE. Potential solutions include development of data and evidence review standards, payer engagement in RWE study design, use of incentives and partnerships to lower the barriers to RWE generation, education of payers and providers concerning the use of RWE and NGS, and frameworks for conducting outcomes-based contracting for NGS. CONCLUSIONS We provide numerous suggestions to overcome the data, methodologic, infrastructure, and policy challenges constraining greater integration of RWE in assessments of NGS.
Collapse
Affiliation(s)
| | - Michael P Douglas
- Center for Translational and Policy Research on Personalized Medicine, Department of Clinical Pharmacy, University of California at San Francisco, San Francisco, CA, USA
| | - Kathryn A Phillips
- Center for Translational and Policy Research on Personalized Medicine, Department of Clinical Pharmacy, University of California at San Francisco, San Francisco, CA, USA; Philip R. Lee Institute for Health Policy, University of California, San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer, University of California at San Francisco, San Francisco, CA, USA
| |
Collapse
|
20
|
Trosman JR, Weldon CB, Slavotinek A, Norton ME, Douglas MP, Phillips KA. Perspectives of US private payers on insurance coverage for pediatric and prenatal exome sequencing: Results of a study from the Program in Prenatal and Pediatric Genomic Sequencing (P3EGS). Genet Med 2019; 22:283-291. [PMID: 31501586 DOI: 10.1038/s41436-019-0650-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 08/26/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Exome sequencing (ES) has the potential to improve management of congenital anomalies and neurodevelopmental disorders in fetuses, infants, and children. US payers are key stakeholders in patient access to ES. We examined how payers view insurance coverage and clinical utility of pediatric and prenatal ES. METHODS We employed the framework approach of qualitative research to conduct this study. The study cohort represented 14 payers collectively covering 170,000,000 enrollees. RESULTS Seventy-one percent of payers covered pediatric ES despite perceived insufficient evidence because they saw merit in available interventions or in ending the diagnostic odyssey. None covered prenatal ES, because they saw no merit. For pediatric ES, 50% agreed with expanded aspects of clinical utility (e.g., information utility), and 21% considered them sufficient for coverage. For prenatal ES, payers saw little utility until in utero interventions become available. CONCLUSION The perceived merit of ES is becoming a factor in payers' coverage for serious diseases with available interventions, even when evidence is perceived insufficient. Payers' views on ES's clinical utility are expanding to include informational utility, aligning with the views of patients and other stakeholders. Our findings inform clinical research, patient advocacy, and policy-making, allowing them to be more relevant to payers.
Collapse
Affiliation(s)
- Julia R Trosman
- Department of Clinical Pharmacy; Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California-San Francisco, San Francisco, CA, USA. .,Center for Business Models in Healthcare, San Francisco, CA, USA.
| | - Christine B Weldon
- Department of Clinical Pharmacy; Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California-San Francisco, San Francisco, CA, USA.,Center for Business Models in Healthcare, San Francisco, CA, USA
| | - Anne Slavotinek
- Department of Pediatrics, University of California-San Francisco, San Francisco, CA, USA
| | - Mary E Norton
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal Fetal Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Michael P Douglas
- Department of Clinical Pharmacy; Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California-San Francisco, San Francisco, CA, USA
| | - Kathryn A Phillips
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), UCSF Philip R. Lee Institute for Health Policy, and UCSF Helen Diller Family Comprehensive Cancer Center, University of California-San Francisco, San Francisco, CA, USA
| |
Collapse
|
21
|
Affiliation(s)
- Kathryn A. Phillips
- UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS); Department of Clinical Pharmacy, University of California San Francisco
- UCSF Philip R. Lee Institute for Health Policy Studies
| | - Julia R. Trosman
- UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS); Department of Clinical Pharmacy, University of California San Francisco
- Center for Business Models in Healthcare
| | - Michael P. Douglas
- UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS); Department of Clinical Pharmacy, University of California San Francisco
| |
Collapse
|
22
|
Phillips KA, Deverka PA, Hooker GW, Douglas MP. Genetic Test Availability And Spending: Where Are We Now? Where Are We Going? Health Aff (Millwood) 2019; 37:710-716. [PMID: 29733704 DOI: 10.1377/hlthaff.2017.1427] [Citation(s) in RCA: 131] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Genetic testing and spending on that testing have grown rapidly since the mapping of the human genome in 2003. However, it is not widely known how many tests there are, how they are used, and how they are paid for. Little evidence from large data sets about their use has emerged. We shed light on the issue of genetic testing by providing an overview of the testing landscape. We examined test availability and spending for the full spectrum of genetic tests, using unique data sources on test availability and commercial payer spending for privately insured populations, focusing particularly on tests measuring multiple genes in the period 2014-17. We found that there were approximately 75,000 genetic tests on the market, with about ten new tests entering the market daily. Prenatal tests accounted for the highest percentage of spending on genetic tests, and spending on hereditary cancer tests accounted for the second-highest. Our results provide insights for those interested in assessing genetic testing markets, test usage, and health policy implications, including current debates over the most appropriate regulatory and payer coverage mechanisms.
Collapse
Affiliation(s)
- Kathryn A Phillips
- Kathryn A. Phillips ( ) is a professor of health economics and health services research in the Center for Translational and Policy Research on Personalized Medicine, Department of Clinical Pharmacy, University of California San Francisco (UCSF)
| | - Patricia A Deverka
- Patricia A. Deverka is a senior researcher at the American Institutes for Research, in Chapel Hill, North Carolina
| | - Gillian W Hooker
- Gillian W. Hooker is vice president of clinical development at Concert Genetics, in Franklin, Tennessee
| | - Michael P Douglas
- Michael P. Douglas is a program manager in the Center for Translational and Policy Research on Personalized Medicine, Department of Clinical Pharmacy, UCSF
| |
Collapse
|
23
|
Phillips KA, Deverka PA, Trosman JR, Douglas MP, Chambers JD, Weldon CB, Dervan AP. Payer coverage policies for multigene tests. Nat Biotechnol 2019; 35:614-617. [PMID: 28700544 DOI: 10.1038/nbt.3912] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Kathryn A Phillips
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco, California, USA.,Philip R. Lee Institute for Health Policy, University of California San Francisco, San Francisco, California, USA.,Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California, USA
| | - Patricia A Deverka
- American Institutes for Research, Chapel Hill, North Carolina, USA.,University of North Carolina, Eshelman School of Pharmacy, Center for Pharmacogenomics and Individualized Therapy, Chapel Hill, North Carolina, USA
| | - Julia R Trosman
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco, California, USA.,Center for Business Models in Healthcare, Chicago, Illinois, USA.,Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael P Douglas
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco, California, USA
| | - James D Chambers
- The Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies.,Tufts Medical Center, Boston, Massachusetts, USA
| | - Christine B Weldon
- Center for Business Models in Healthcare, Chicago, Illinois, USA.,Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Andrew P Dervan
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Washington, USA
| |
Collapse
|
24
|
Phillips KA, Douglas MP. The Global Market for Next-Generation Sequencing Tests Continues Its Torrid Pace. J Precis Med 2018; 4:https://www.thejournalofprecisionmedicine.com/wp-content/uploads/2018/11/Phillips-Online.pdf. [PMID: 32149190 PMCID: PMC7059995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The market for next-generation sequencing technologies (NGS) has grown dramatically. Health care decision-makers need empirical evidence on market growth and future trends in order to develop appropriate strategies and policies, but little has been published about the nature and size of these trends. We provide a snapshot of market trends through 2020. We found rapid growth of clinical NGS - the global clinical NGS services market was $2.2 billion in 2015 and is forecast to reach $7.7 billion by 2020. The reproductive health NGS test market is the largest market followed by the oncology NGS test market. The largest market is for tests that sequence >50 genes but not the entire exome or genome. Markets are growing rapidly in countries outside of the US. Despite rapid NGS test growth, there are a number of key issues that will need to be addressed to facilitate appropriate future growth.
Collapse
Affiliation(s)
- Kathryn A. Phillips
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco
- Philip R. Lee Institute for Health Policy, University of California San Francisco, San Francisco
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco
| | - Michael P. Douglas
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco
| |
Collapse
|
25
|
Douglas MP, Parker SL, Trosman JR, Slavotinek AM, Phillips KA. Private payer coverage policies for exome sequencing (ES) in pediatric patients: trends over time and analysis of evidence cited. Genet Med 2018; 21:152-160. [PMID: 29997388 PMCID: PMC6329652 DOI: 10.1038/s41436-018-0043-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 04/05/2018] [Indexed: 11/16/2022] Open
Abstract
Purpose Whole Exome Sequencing (WES) is being adopted for neurodevelopmental
disorders in pediatric patients. However, little is known about current
coverage policies or the evidence cited supporting these policies. Our study
is the first in-depth review of private payer WES coverage policies for
pediatric patients with neurodevelopmental disorders. Methods We reviewed private payer coverage policies and examined evidence
cited in the policies of the 15 largest payers in 2017, and trends in
coverage policies and evidence cited (2015 – 2017) for the five
largest payers. Results There were four relevant policies (N=5 payers) in 2015 and 13
policies (N=15 payers) in 2017. In 2015, no payer covered WES, but
by 2017, three payers from the original registry payers did. In 2017, eight
of the 15 payers covered WES. We found variations in the number and types of
evidence cited. Positive coverage policies tended to include a larger number
and range of citations. Conclusion We conclude that more systematic assessment of evidence cited in
coverage policies can provide a greater understanding of coverage policies
and how evidence is used. Such assessments could facilitate the ability of
researchers to provide the needed evidence, and the ability of clinicians to
provide the most appropriate testing for patients.
Collapse
Affiliation(s)
- Michael P Douglas
- University of California at San Francisco, Department of Clinical Pharmacy; Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), 3333 California St, Room 420, Box 0613, San Francisco, California, USA.
| | | | - Julia R Trosman
- Center for Business Models in Healthcare, San Francisco, California, USA
| | - Anne M Slavotinek
- University of California, San Francisco, Department of Pediatrics, San Francisco, California, USA
| | - Kathryn A Phillips
- University of California at San Francisco, Department of Clinical Pharmacy; Center for Translational and Policy Research on Personalized Medicine (TRANSPERS); UCSF Philip R. Lee Institute for Health Policy; and UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California, USA
| |
Collapse
|
26
|
Phillips KA, Trosman JR, Deverka PA, Quinn B, Tunis S, Neumann PJ, Chambers JD, Garrison LP, Douglas MP, Weldon CB. Insurance coverage for genomic tests. Science 2018; 360:278-279. [PMID: 29674586 DOI: 10.1126/science.aas9268] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Kathryn A Phillips
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco CA 94143, USA. .,Philip R. Lee Institute for Health Policy, San Francisco, CA 94118, USA.,Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Julia R Trosman
- Center for Business Models in Healthcare, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Patricia A Deverka
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco CA 94143, USA.,American Institutes for Research, Chapel Hill, NC 27517, USA
| | - Bruce Quinn
- Bruce Quinn Associates, Los Angeles, CA 90036, USA
| | - Sean Tunis
- Center for Medical Technology Policy (CMTP), Baltimore, MD 21202, USA
| | - Peter J Neumann
- The Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA 02111, USA
| | - James D Chambers
- The Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA 02111, USA
| | - Louis P Garrison
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, WA 98195, USA
| | - Michael P Douglas
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco CA 94143, USA
| | - Christine B Weldon
- Center for Business Models in Healthcare, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| |
Collapse
|
27
|
Christensen KD, Vassy JL, Phillips KA, Blout CL, Azzariti DR, Lu CY, Robinson JO, Lee K, Douglas MP, Yeh JM, Machini K, Stout NK, Rehm HL, McGuire AL, Green RC, Dukhovny D. Short-term costs of integrating whole-genome sequencing into primary care and cardiology settings: a pilot randomized trial. Genet Med 2018; 20:1544-1553. [PMID: 29565423 PMCID: PMC6151171 DOI: 10.1038/gim.2018.35] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 01/30/2018] [Indexed: 12/26/2022] Open
Abstract
Purpose Great uncertainty exists about the costs associated with whole genome sequencing (WGS). Methods One hundred cardiology patients with cardiomyopathy diagnoses, and 100 ostensibly healthy primary care patients were randomized to receive a family history report alone or with a WGS report. Cardiology patients also reviewed prior genetic test results. WGS costs were estimated by tracking resource use and staff time. Downstream costs were estimated by identifying services in administrative data, medical records, and patient surveys for 6 months. Results The incremental cost per patient of WGS testing was $5,098 in cardiology settings and $5,073 in primary care settings compared to family history alone. Mean six month downstream costs did not differ statistically between the control and WGS arms in either setting (cardiology: difference = −$1,560, 95%CI −$7,558 to $3,866, p=0.36; primary care: difference = $681, 95%CI −$884 to $2,171, p=0.70). Scenario analyses showed the cost reduction of omitting or limiting the types of secondary findings was less than $69 and $182 per patient in cardiology and primary care, respectively. Conclusion Short-term costs of WGS were driven by the costs of sequencing and interpretation rather than downstream healthcare. Disclosing additional types of secondary findings has a limited cost impact following disclosure.
Collapse
Affiliation(s)
- Kurt D Christensen
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA. .,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.
| | - Jason L Vassy
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Section of General Internal Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Kathryn A Phillips
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco, California, USA.,Philip R. Lee Institute for Health Policy and Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California, USA
| | - Carrie L Blout
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Danielle R Azzariti
- Partners HealthCare Laboratory for Molecular Medicine, Cambridge, Massachusetts, USA
| | - Christine Y Lu
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Department of Population Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jill O Robinson
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
| | - Kaitlyn Lee
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
| | - Michael P Douglas
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco, California, USA
| | - Jennifer M Yeh
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kalotina Machini
- Partners HealthCare Laboratory for Molecular Medicine, Cambridge, Massachusetts, USA.,Department of Pathology, Harvard Medical School, Boston, Massachusetts, USA.,Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Natasha K Stout
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Department of Population Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Heidi L Rehm
- Partners HealthCare Laboratory for Molecular Medicine, Cambridge, Massachusetts, USA.,Department of Pathology, Harvard Medical School, Boston, Massachusetts, USA.,Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Amy L McGuire
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
| | - Robert C Green
- Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA.,Partners HealthCare Personalized Medicine, Boston, Massachusetts, USA
| | - Dmitry Dukhovny
- Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, USA
| | | |
Collapse
|
28
|
Phillips KA, Trosman JR, Weldon CB, Douglas MP. New Medicare Coverage Policy for Next-Generation Tumor Sequencing: A Key Shift in Coverage Criteria With Broad Implications Beyond Medicare. JCO Precis Oncol 2018; 2. [PMID: 31073549 DOI: 10.1200/po.18.00206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- K A Phillips
- University of California at San Francisco, Department of Clinical Pharmacy.,Center for Translational and Policy Research on Personalized Medicine (TRANSPERS).,UCSF Philip R. Lee Institute for Health Policy.,UCSF Helen Diller Family Comprehensive Cancer Center
| | - J R Trosman
- University of California at San Francisco, Department of Clinical Pharmacy.,Center for Translational and Policy Research on Personalized Medicine (TRANSPERS).,Center for Business Models in Healthcare
| | - C B Weldon
- Center for Translational and Policy Research on Personalized Medicine (TRANSPERS).,Center for Business Models in Healthcare
| | - M P Douglas
- University of California at San Francisco, Department of Clinical Pharmacy.,Center for Translational and Policy Research on Personalized Medicine (TRANSPERS)
| |
Collapse
|
29
|
Phillips KA, Deverka PA, Sox HC, Khoury MJ, Sandy LG, Ginsburg GS, Tunis SR, Orlando LA, Douglas MP. Making genomic medicine evidence-based and patient-centered: a structured review and landscape analysis of comparative effectiveness research. Genet Med 2017; 19:1081-1091. [PMID: 28406488 PMCID: PMC5629101 DOI: 10.1038/gim.2017.21] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 01/24/2017] [Indexed: 01/15/2023] Open
Abstract
Comparative effectiveness research (CER) in genomic medicine (GM) measures the clinical utility of using genomic information to guide clinical care in comparison to appropriate alternatives. We summarized findings of high-quality systematic reviews that compared the analytic and clinical validity and clinical utility of GM tests. We focused on clinical utility findings to summarize CER-derived evidence about GM and identify evidence gaps and future research needs. We abstracted key elements of study design, GM interventions, results, and study quality ratings from 21 systematic reviews published in 2010 through 2015. More than half (N = 13) of the reviews were of cancer-related tests. All reviews identified potentially important clinical applications of the GM interventions, but most had significant methodological weaknesses that largely precluded any conclusions about clinical utility. Twelve reviews discussed the importance of patient-centered outcomes, although few described evidence about the impact of genomic medicine on these outcomes. In summary, we found a very limited body of evidence about the effect of using genomic tests on health outcomes and many evidence gaps for CER to address.Genet Med advance online publication 13 April 2017.
Collapse
Affiliation(s)
- Kathryn A. Phillips
- Department of Clinical Pharmacy, Center
for Translational and Policy Research on Personalized Medicine (TRANSPERS), UCSF
Philip R. Lee Institute for Health Policy and UCSF Helen Diller Family
Comprehensive Cancer Center, University of California at San Francisco,
San Francisco, California, USA
| | | | - Harold C. Sox
- Patient-Centered Outcomes Research
Institute, Washington, DC, USA
| | - Muin J. Khoury
- Office of Public Health Genomics, US
Centers for Disease Control and Prevention, Atlanta,
Georgia, USA
| | | | - Geoffrey S. Ginsburg
- Duke Center for Applied Genomics and
Precision Medicine, Duke University Medical Center, Durham,
North Carolina, USA
| | - Sean R. Tunis
- Center for Medical Technology
Policy, Baltimore, Maryland, USA
| | - Lori A. Orlando
- Division of General Internal Medicine,
Department of Medicine, Duke University Medical Center, Durham,
North Carolina, USA
| | - Michael P. Douglas
- University of California at San
Francisco, Department of Clinical Pharmacy, Center for Translational and Policy
Research on Personalized Medicine (TRANSPERS), San Francisco,
California, USA
| |
Collapse
|
30
|
Marshall DA, MacDonald KV, Robinson JO, Barcellos LF, Gianfrancesco M, Helm M, McGuire A, Green RC, Douglas MP, Goldman MA, Phillips KA. The price of whole-genome sequencing may be decreasing, but who will be sequenced? Per Med 2017; 14:203-211. [PMID: 28993792 DOI: 10.2217/pme-2016-0075] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM Since whole-genome sequencing (WGS) information can have positive and negative personal utility for individuals, we examined predictors of willingness to pay (WTP) for WGS. PATIENTS & METHODS We surveyed two independent populations: adult patients (n = 203) and college seniors (n = 980). Ordinal logistic regression models were used to characterize the relationship between predictors and WTP. RESULTS Sex, age, education, income, genomic knowledge and knowing someone who had genetic testing or having had genetic testing done personally were associated with significantly higher WTP for WGS. After controlling for income and education, males were willing to pay more for WGS than females. CONCLUSION Differences in WTP may impact equity, coverage, affordability and access, and should be anticipated by public dialog about related health policy.
Collapse
Affiliation(s)
- Deborah A Marshall
- Department of Community Health Sciences, Room 3C56 Health Research Innovation Centre, University of Calgary, Calgary, Alberta, Canada
| | - Karen V MacDonald
- Department of Community Health Sciences, Room 3C56 Health Research Innovation Centre, University of Calgary, Calgary, Alberta, Canada
| | - Jill Oliver Robinson
- Center for Medical Ethics & Health Policy, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, USA
| | - Lisa F Barcellos
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Milena Gianfrancesco
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA
| | - Monica Helm
- Center for Clinical Genetics and Genomics at Providence Health & Services Southern California, 181 South Buena Vista Street - Suite 240, Burbank, CA 91505, USA
| | - Amy McGuire
- Center for Medical Ethics & Health Policy, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, USA
| | - Robert C Green
- Division of Genetics, Department of Medicine, Brigham & Women's Hospital, Broad Institute & Harvard Medical School, Boston, MA, USA
| | - Michael P Douglas
- Department of Clinical Pharmacy, Center for Translational & Policy Research on Personalized Medicine (TRANSPERS), University of California, San Francisco, CA, USA
| | - Michael A Goldman
- Department of Biology, College of Science & Engineering, San Francisco State University, San Francisco, CA, USA
| | - Kathryn A Phillips
- Department of Clinical Pharmacy, Center for Translational & Policy Research on Personalized Medicine (TRANSPERS), University of California, San Francisco, CA, USA.,UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| |
Collapse
|
31
|
Trosman JR, Weldon CB, Douglas MP, Kurian AW, Kelley RK, Deverka PA, Phillips KA. Payer Coverage for Hereditary Cancer Panels: Barriers, Opportunities, and Implications for the Precision Medicine Initiative. J Natl Compr Canc Netw 2017; 15:219-228. [PMID: 28188191 DOI: 10.6004/jnccn.2017.0022] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 11/08/2016] [Indexed: 12/20/2022]
Abstract
Background: Hereditary cancer panels (HCPs), testing for multiple genes and syndromes, are rapidly transforming cancer risk assessment but are controversial and lack formal insurance coverage. We aimed to identify payers' perspectives on barriers to HCP coverage and opportunities to address them. Comprehensive cancer risk assessment is highly relevant to the Precision Medicine Initiative (PMI), and payers' considerations could inform PMI's efforts. We describe our findings and discuss them in the context of PMI priorities. Methods: We conducted semi-structured interviews with 11 major US payers, covering >160 million lives. We used the framework approach of qualitative research to design, conduct, and analyze interviews, and used simple frequencies to further describe findings. Results: Barriers to HCP coverage included poor fit with coverage frameworks (100%); insufficient evidence (100%); departure from pedigree/family history-based testing toward genetic screening (91%); lacking rigor in the HCP hybrid research/clinical setting (82%); and patient transparency and involvement concerns (82%). Addressing barriers requires refining HCP-indicated populations (82%); developing evidence of actionability (82%) and pathogenicity/penetrance (64%); creating infrastructure and standards for informing and recontacting patients (45%); separating research from clinical use in the hybrid clinical-research setting (44%); and adjusting coverage frameworks (18%). Conclusions: Leveraging opportunities suggested by payers to address HCP coverage barriers is essential to ensure patients' access to evolving HCPs. Our findings inform 3 areas of the PMI: addressing insurance coverage to secure access to future PMI discoveries; incorporating payers' evidentiary requirements into PMI's research agenda; and leveraging payers' recommendations and experience to keep patients informed and involved.
Collapse
Affiliation(s)
- Julia R Trosman
- UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), Department of Clinical Pharmacy, University of California, San Francisco, San Franscisco, California,Center for Business Models in Healthcare, Chicago, Illinois,Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Christine B Weldon
- UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), Department of Clinical Pharmacy, University of California, San Francisco, San Franscisco, California,Center for Business Models in Healthcare, Chicago, Illinois,Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Michael P Douglas
- UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), Department of Clinical Pharmacy, University of California, San Francisco, San Franscisco, California
| | - Allison W Kurian
- Departments of Medicine and of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - R Kate Kelley
- UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), Department of Clinical Pharmacy, University of California, San Francisco, San Franscisco, California,Department of Medicine, Division of Hematology/Oncology, University of California, San Francisco, San Francisco, Califorina,Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California
| | | | - Kathryn A Phillips
- UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), Department of Clinical Pharmacy, University of California, San Francisco, San Franscisco, California,Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California,Philip R. Lee Institute for Health Policy, University of California, San Francisco, San Francisco, California
| |
Collapse
|
32
|
Trosman JR, Weldon CB, Douglas MP, Deverka PA, Watkins JB, Phillips KA. Decision Making on Medical Innovations in a Changing Health Care Environment: Insights from Accountable Care Organizations and Payers on Personalized Medicine and Other Technologies. Value Health 2017; 20:40-46. [PMID: 28212967 PMCID: PMC5319741 DOI: 10.1016/j.jval.2016.09.2402] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 09/18/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND New payment and care organization approaches, such as those of accountable care organizations (ACOs), are reshaping accountability and shifting risk, as well as decision making, from payers to providers, within the Triple Aim context of health reform. The Triple Aim calls for improving experience of care, improving health of populations, and reducing health care costs. OBJECTIVES To understand how the transition to the ACO model impacts decision making on adoption and use of innovative technologies in the era of accelerating scientific advancement of personalized medicine and other innovations. METHODS We interviewed representatives from 10 private payers and 6 provider institutions involved in implementing the ACO model (i.e., ACOs) to understand changes, challenges, and facilitators of decision making on medical innovations, including personalized medicine. We used the framework approach of qualitative research for study design and thematic analysis. RESULTS We found that representatives from the participating payer companies and ACOs perceive similar challenges to ACOs' decision making in terms of achieving a balance between the components of the Triple Aim-improving care experience, improving population health, and reducing costs. The challenges include the prevalence of cost over care quality considerations in ACOs' decisions and ACOs' insufficient analytical and technology assessment capacity to evaluate complex innovations such as personalized medicine. Decision-making facilitators included increased competition across ACOs and patients' interest in personalized medicine. CONCLUSIONS As new payment models evolve, payers, ACOs, and other stakeholders should address challenges and leverage opportunities to arm ACOs with robust, consistent, rigorous, and transparent approaches to decision making on medical innovations.
Collapse
Affiliation(s)
- Julia R Trosman
- UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), Department of Clinical Pharmacy, University of California, San Franscisco, CA, USA; Center for Business Models in Healthcare, Chicago, IL, USA; Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Christine B Weldon
- UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), Department of Clinical Pharmacy, University of California, San Franscisco, CA, USA; Center for Business Models in Healthcare, Chicago, IL, USA; Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michael P Douglas
- UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), Department of Clinical Pharmacy, University of California, San Franscisco, CA, USA
| | | | | | - Kathryn A Phillips
- UCSF Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), Department of Clinical Pharmacy, University of California, San Franscisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA; Philip R. Lee Institute for Health Policy, University of California, San Francisco, CA, USA
| |
Collapse
|
33
|
Phillips KA, Douglas MP, Trosman JR, Marshall DA. "What Goes Around Comes Around": Lessons Learned from Economic Evaluations of Personalized Medicine Applied to Digital Medicine. Value Health 2017; 20:47-53. [PMID: 28212968 PMCID: PMC5319740 DOI: 10.1016/j.jval.2016.08.736] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 08/20/2016] [Indexed: 05/03/2023]
Abstract
BACKGROUND The growth of "big data" and the emphasis on patient-centered health care have led to the increasing use of two key technologies: personalized medicine and digital medicine. For these technologies to move into mainstream health care and be reimbursed by insurers, it will be essential to have evidence that their benefits provide reasonable value relative to their costs. These technologies, however, have complex characteristics that present challenges to the assessment of their economic value. Previous studies have identified the challenges for personalized medicine and thus this work informs the more nascent topic of digital medicine. OBJECTIVES To examine the methodological challenges and future opportunities for assessing the economic value of digital medicine, using personalized medicine as a comparison. METHODS We focused specifically on digital biomarker technologies and multigene tests. We identified similarities in these technologies that can present challenges to economic evaluation: multiple results, results with different types of utilities, secondary findings, downstream impact (including on family members), and interactive effects. RESULTS Using a structured review, we found that there are few economic evaluations of digital biomarker technologies, with limited results. CONCLUSIONS We conclude that more evidence on the effectiveness of digital medicine will be needed but that the experiences with personalized medicine can inform what data will be needed and how such analyses can be conducted. Our study points out the critical need for typologies and terminology for digital medicine technologies that would enable them to be classified in ways that will facilitate research on their effectiveness and value.
Collapse
Affiliation(s)
- Kathryn A Phillips
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Peronalized Medicine (TRANSPERS), University of California San Francisco, San Francisco, CA, USA; Philip R. Lee Institute for Health Policy, University of California San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA.
| | - Michael P Douglas
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Peronalized Medicine (TRANSPERS), University of California San Francisco, San Francisco, CA, USA
| | - Julia R Trosman
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Peronalized Medicine (TRANSPERS), University of California San Francisco, San Francisco, CA, USA; Center for Business Models in Healthcare, Chicago, IL, USA; Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Deborah A Marshall
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
34
|
Phillips KA, Trosman JR, Kelley RK, Pletcher MJ, Douglas MP, Weldon CB. Genomic sequencing: assessing the health care system, policy, and big-data implications. Health Aff (Millwood) 2016; 33:1246-53. [PMID: 25006153 DOI: 10.1377/hlthaff.2014.0020] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
New genomic sequencing technologies enable the high-speed analysis of multiple genes simultaneously, including all of those in a person's genome. Sequencing is a prominent example of a "big data" technology because of the massive amount of information it produces and its complexity, diversity, and timeliness. Our objective in this article is to provide a policy primer on sequencing and illustrate how it can affect health care system and policy issues. Toward this end, we developed an easily applied classification of sequencing based on inputs, methods, and outputs. We used it to examine the implications of sequencing for three health care system and policy issues: making care more patient-centered, developing coverage and reimbursement policies, and assessing economic value. We conclude that sequencing has great promise but that policy challenges include how to optimize patient engagement as well as privacy, develop coverage policies that distinguish research from clinical uses and account for bioinformatics costs, and determine the economic value of sequencing through complex economic models that take into account multiple findings and downstream costs.
Collapse
Affiliation(s)
- Kathryn A Phillips
- Kathryn A. Phillips is a professor in the Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), the Department of Clinical Pharmacy, the Philip R. Lee Institute for Health Policy, and the Helen Diller Family Comprehensive Cancer Center, all at the University of California, San Francisco (UCSF)
| | - Julia R Trosman
- Julia R. Trosman is codirector of the Center for Business Models in Healthcare, in Chicago, Illinois, and an adjunct faculty member in the Department of Clinical Pharmacy, UCSF
| | - Robin K Kelley
- Robin K. Kelley is an assistant clinical professor in the Department of Medicine, Division of Hematology/Oncology, UCSF
| | - Mark J Pletcher
- Mark J. Pletcher is an associate professor in the Department of Epidemiology and Biostatistics and the Department of Medicine, UCSF
| | - Michael P Douglas
- Michael P. Douglas is a program manager in TRANSPERS and the Department of Clinical Pharmacy, UCSF
| | - Christine B Weldon
- Christine B. Weldon is codirector of the Center for Business Models in Healthcare and an adjunct faculty member in the Feinberg School of Medicine, Northwestern University, in Chicago
| |
Collapse
|
35
|
Marshall DA, Gonzalez JM, Johnson FR, MacDonald KV, Pugh A, Douglas MP, Phillips KA. What are people willing to pay for whole-genome sequencing information, and who decides what they receive? Genet Med 2016; 18:1295-1302. [PMID: 27253734 PMCID: PMC5133139 DOI: 10.1038/gim.2016.61] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 03/30/2016] [Indexed: 01/31/2023] Open
Abstract
PURPOSE Whole genome sequencing (WGS) can be used as a powerful diagnostic tool which could also be used for screening but may generate anxiety, unnecessary testing and overtreatment. Current guidelines suggest reporting clinically actionable secondary findings when diagnostic testing is performed. We estimated preferences for receiving WGS results. METHODS A US nationally representative survey (n=410 adults) was used to rank preferences for who decides (expert panel, your doctor, you) which WGS results are reported. We estimated the value of information about variants with varying levels of clinical usefulness using willingness-to-pay contingent valuation questions. RESULTS 43% preferred to decide themselves what information is included in the WGS report. 38% (95% CI:33–43%) would not pay for actionable variants, and 3% (95% CI:1–5%) would pay more than $1000. 55% (95% CI:50–60%) would not pay for variants in which medical treatment is currently unclear, and 7% (95% CI:5–9%) would pay more than $400. CONCLUSION Most people prefer to decide what WGS results are reported. Despite valuing actionable information more, some respondents perceive that genetic information could negatively impact them. Preference heterogeneity for WGS information should be considered in the development of policies, particularly to integrate patient preferences with personalized medicine and shared decision making.
Collapse
Affiliation(s)
- Deborah A Marshall
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - F Reed Johnson
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Karen V MacDonald
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Amy Pugh
- Research Triangle Institute, Research Triangle Park, North Carolina, USA
| | - Michael P Douglas
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California at San Francisco, San Francisco, California, USA
| | - Kathryn A Phillips
- UCSF Philip R. Lee Institute for Health Policy, University of California at San Francisco, San Francisco, California, USA.,UCSF Helen Diller Family Comprehensive Cancer Center, University of California at San Francisco, San Francisco, California, USA
| |
Collapse
|
36
|
Phillips KA, Ladabaum U, Pletcher MJ, Marshall DA, Douglas MP. Key emerging themes for assessing the cost-effectiveness of reporting incidental findings. Genet Med 2016; 17:314-5. [PMID: 25835195 DOI: 10.1038/gim.2015.13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 12/12/2014] [Indexed: 11/09/2022] Open
Affiliation(s)
- Kathryn A Phillips
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), Philip R. Lee Institute for Health Policy; and Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California, USA
| | - Uri Ladabaum
- 1] School of Medicine, Stanford University, Sanford, California, USA [2] Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco, California, USA
| | - Mark J Pletcher
- 1] Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco, California, USA [2] Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Deborah A Marshall
- 1] Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco, California, USA [2] Department of Community Health Sciences, Cumming School of Medicine; O`Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Michael P Douglas
- Department of Clinical Pharmacy, Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
37
|
Trosman JR, Weldon CB, Kurian AW, Douglas MP, Kelley RK, Phillips KA. Addressing lack of US insurance coverage of Cancer Hereditary Multiplex Testing (CHMT). J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.e17515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | - Robin Kate Kelley
- University of California, San Francisco Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | - Kathryn A Phillips
- Center for Translational and Policy Research on Personalized Medicine (TRANSPERS), University of California, San Francisco, San Francisco, CA
| |
Collapse
|
38
|
Garfeld S, Douglas MP, MacDonald KV, Marshall DA, Phillips KA. Consumer familiarity, perspectives and expected value of personalized medicine with a focus on applications in oncology. Per Med 2015; 12:13-22. [PMID: 25620993 DOI: 10.2217/pme.14.74] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
AIMS Knowledge of consumer perspectives of personalized medicine (PM) is limited. Our study assessed consumer perspectives of PM, with a focus on oncology care, to inform industry, clinician and payer stakeholders' programs and policy. MATERIALS & METHODS A nationally representative survey of 602 US consumers' ≥30 years old explored familiarity, perspectives and expected value of PM. RESULTS Most (73%) respondents have not heard of 'personalized medicine,' though after understanding the term most (95%) expect PM to have a positive beneft. Consumer's willingness to pay is associated with products' impact on survival, rather than predicting disease risk. If testing indicates consumers are not candidates for oncology therapies, most (84%) would seek a second opinion or want therapy anyway. CONCLUSIONS Understanding heterogeneity in consumer perspectives of PM can inform program and policy development.
Collapse
Affiliation(s)
| | - Michael P Douglas
- Department of Clinical Pharmacy, Center for Translational & Policy Research on Personalized Medicine (TRANSPERS), University of California at San Francisco, 3333 California St, Room 420, Box 0613 San Francisco, CA 94143 USA
| | - Karen V MacDonald
- Health Research Innovation Centre (HRIC) - 3C62, University of Calgary, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6, USA
| | - Deborah A Marshall
- Health Research Innovation Centre (HRIC) - 3C62, University of Calgary, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6, USA
| | - Kathryn A Phillips
- Department of Clinical Pharmacy, Center for Translational & Policy Research on Personalized Medicine (TRANSPERS), University of California at San Francisco, 3333 California St, Room 420, Box 0613 San Francisco, CA 94143 USA
| |
Collapse
|
39
|
Dotson WD, Douglas MP, Kolor K, Stewart AC, Bowen MS, Gwinn M, Wulf A, Anders HM, Chang CQ, Clyne M, Lam TK, Schully SD, Marrone M, Feero WG, Khoury MJ. Prioritizing genomic applications for action by level of evidence: a horizon-scanning method. Clin Pharmacol Ther 2014; 95:394-402. [PMID: 24398597 PMCID: PMC4689130 DOI: 10.1038/clpt.2013.226] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 11/08/2013] [Indexed: 11/09/2022]
Abstract
As evidence accumulates on the use of genomic tests and other health-related applications of genomic technologies, decision makers may increasingly seek support in identifying which applications have sufficiently robust evidence to suggest they might be considered for action. As an interim working process to provide such support, we developed a horizon-scanning method that assigns genomic applications to tiers defined by availability of synthesized evidence. We illustrate an application of the method to pharmacogenomics tests.
Collapse
Affiliation(s)
- WD Dotson
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - MP Douglas
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- McKing Consulting Corporation, Atlanta, Georgia, USA
| | - K Kolor
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - AC Stewart
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- McKing Consulting Corporation, Atlanta, Georgia, USA
| | - MS Bowen
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - M Gwinn
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- McKing Consulting Corporation, Atlanta, Georgia, USA
| | - A Wulf
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Cadence Group, Atlanta, Georgia, USA
| | - HM Anders
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- McKing Consulting Corporation, Atlanta, Georgia, USA
| | - CQ Chang
- Epidemiology and Genomics Research Program, National Cancer Institute, Bethesda, Maryland, USA
| | - M Clyne
- Epidemiology and Genomics Research Program, National Cancer Institute, Bethesda, Maryland, USA
- Kelly Services, Troy, Michigan, USA
| | - TK Lam
- Epidemiology and Genomics Research Program, National Cancer Institute, Bethesda, Maryland, USA
| | - SD Schully
- Epidemiology and Genomics Research Program, National Cancer Institute, Bethesda, Maryland, USA
| | - M Marrone
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - WG Feero
- Maine Dartmouth Family Medicine Residency Program, Augusta, Maine, USA
| | - MJ Khoury
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Epidemiology and Genomics Research Program, National Cancer Institute, Bethesda, Maryland, USA
| |
Collapse
|
40
|
Phillips KA, Ann Sakowski J, Trosman J, Douglas MP, Liang SY, Neumann P. The economic value of personalized medicine tests: what we know and what we need to know. Genet Med 2014; 16:251-7. [PMID: 24232413 PMCID: PMC3949119 DOI: 10.1038/gim.2013.122] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 07/09/2013] [Indexed: 11/09/2022] Open
Abstract
PURPOSE There is uncertainty about when personalized medicine tests provide economic value. We assessed evidence on the economic value of personalized medicine tests and gaps in the evidence base. METHODS We created a unique evidence base by linking data on published cost-utility analyses from the Tufts Cost-Effectiveness Analysis Registry with data measuring test characteristics and reflecting where value analyses may be most needed: (i) tests currently available or in advanced development, (ii) tests for drugs with Food and Drug Administration labels with genetic information, (iii) tests with demonstrated or likely clinical utility, (iv) tests for conditions with high mortality, and (v) tests for conditions with high expenditures. RESULTS We identified 59 cost-utility analyses studies that examined personalized medicine tests (1998-2011). A majority (72%) of the cost/quality-adjusted life year ratios indicate that testing provides better health although at higher cost, with almost half of the ratios falling below $50,000 per quality-adjusted life year gained. One-fifth of the results indicate that tests may save money. CONCLUSION Many personalized medicine tests have been found to be relatively cost-effective, although fewer have been found to be cost saving, and many available or emerging medicine tests have not been evaluated. More evidence on value will be needed to inform decision making and assessment of genomic priorities.
Collapse
Affiliation(s)
- Kathryn A Phillips
- 1] Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California, USA [2] UCSF Philip R. Lee Institute for Health Policy, San Francisco, California, USA [3] UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California, USA [4] UCSF Institute for Human Genetics, Center for Business Models in Healthcare, Chicago, Illinois, USA
| | - Julie Ann Sakowski
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California, USA
| | - Julia Trosman
- 1] Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California, USA [2] UCSF Institute for Human Genetics, Center for Business Models in Healthcare, Chicago, Illinois, USA
| | - Michael P Douglas
- 1] Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California, USA [2] McKing Consulting Corporation, Fairfax, Virginia, USA
| | - Su-Ying Liang
- 1] Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California, USA [2] Palo Alto Medical Foundation Research Institute, Palo Alto, California, USA
| | - Peter Neumann
- Center for Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
41
|
Teutsch SM, Bradley LA, Palomaki GE, Haddow JE, Piper M, Calonge N, Dotson WD, Douglas MP, Berg AO. The Evaluation of Genomic Applications in Practice and Prevention (EGAPP) Initiative: methods of the EGAPP Working Group. Genet Med 2009; 11:3-14. [PMID: 18813139 PMCID: PMC2743609 DOI: 10.1097/gim.0b013e318184137c] [Citation(s) in RCA: 460] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The Evaluation of Genomic Applications in Practice and Prevention (EGAPP) Initiative, established by the National Office of Public Health Genomics at the Centers for Disease Control and Prevention, supports the development and implementation of a rigorous, evidence-based process for evaluating genetic tests and other genomic applications for clinical and public health practice in the United States. An independent, non-federal EGAPP Working Group (EWG), a multidisciplinary expert panel selects topics, oversees the systematic review of evidence, and makes recommendations based on that evidence. This article describes the EGAPP processes and details the specific methods and approaches used by the EWG.
Collapse
Affiliation(s)
| | - Linda A. Bradley
- National Office of Public Health Genomics, CDC, Atlanta, Georgia
| | - Glenn E. Palomaki
- Department of Pathology and Laboratory Medicine (Research), The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - James E. Haddow
- Department of Pathology and Laboratory Medicine (Research), The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Margaret Piper
- Blue Cross/Blue Shield Association Technology Evaluation Center, Chicago, Illinois
| | - Ned Calonge
- Colorado Department of Public Health and Environment, Denver, Colorado
| | - W. David Dotson
- National Office of Public Health Genomics, CDC, Atlanta, Georgia
- McKing Consulting Corp., Atlanta, Georgia and
| | - Michael P. Douglas
- National Office of Public Health Genomics, CDC, Atlanta, Georgia
- McKing Consulting Corp., Atlanta, Georgia and
| | - Alfred O. Berg
- Department of Family Medicine, University of Washington, Seattle, Washington
| |
Collapse
|
42
|
Schinsky MF, Morey RE, Steigerwalt AG, Douglas MP, Wilson RW, Floyd MM, Butler WR, Daneshvar MI, Brown-Elliott BA, Wallace RJ, McNeil MM, Brenner DJ, Brown JM. Taxonomic variation in the Mycobacterium fortuitum third biovariant complex: description of Mycobacterium boenickei sp. nov., Mycobacterium houstonense sp. nov., Mycobacterium neworleansense sp. nov. and Mycobacterium brisbanense sp. nov. and recognition of Mycobacterium porcinum from human clinical isolates. Int J Syst Evol Microbiol 2004; 54:1653-1667. [PMID: 15388725 DOI: 10.1099/ijs.0.02743-0] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The Mycobacterium fortuitum third biovariant complex (sorbitol-negative and sorbitol-positive) contains unnamed taxa first characterized in 1991. These organisms can cause respiratory infections, a spectrum of soft tissue and skeletal infections, bacteraemia and disseminated disease. To evaluate this group of organisms, clinical reference isolates and the type strains of M. fortuitum third biovariant complex sorbitol-negative (n=21), M. fortuitum third biovariant complex sorbitol-positive (n=3), M. fortuitum (n=3), Mycobacterium peregrinum (pipemidic acid-susceptible) (n=1), Mycobacterium porcinum (n=1), Mycobacterium senegalense (n=2) and Mycobacterium septicum (n=1) were characterized by using conventional phenotypic (morphological, physiological and antimicrobial susceptibilities), chemotaxonomic (HPLC and cellular fatty acids) and genotypic [RFLP of the rRNA gene (ribotyping), PCR-RFLP of a 439 bp segment of the 65 kDa hsp gene (PCR restriction analysis) and 16S rRNA gene sequence] analysis, DNA G+C content and DNA–DNA relatedness analyses. The results of these studies indicated that the strains comprised M. porcinum (n=13), M. septicum (n=1) and four novel closely related genetic groups within the M. fortuitum third biovariant complex: Mycobacterium boenickei sp. nov. (n=6), Mycobacterium houstonense sp. nov. (n=2), Mycobacterium neworleansense sp. nov. (n=1) and Mycobacterium brisbanense sp. nov. (n=1), with type strains ATCC 49935T (=W5998T=DSM 44677T), ATCC 49403T (=W5198T=DSM 44676T) ATCC 49404T (=W6705T=DSM 44679T) and ATCC 49938T (=W6743T=DSM 44680T), respectively.
Collapse
MESH Headings
- Anti-Bacterial Agents/pharmacology
- Bacterial Typing Techniques
- Base Composition
- Chaperonin 60/genetics
- DNA Fingerprinting
- DNA, Bacterial/chemistry
- DNA, Bacterial/isolation & purification
- DNA, Ribosomal/chemistry
- DNA, Ribosomal/isolation & purification
- Fatty Acids/analysis
- Genes, rRNA/genetics
- Humans
- Microbial Sensitivity Tests
- Molecular Sequence Data
- Mycobacterium Infections, Nontuberculous/microbiology
- Mycobacterium fortuitum/classification
- Mycobacterium fortuitum/genetics
- Mycobacterium fortuitum/isolation & purification
- Mycobacterium fortuitum/physiology
- Mycolic Acids/analysis
- Nontuberculous Mycobacteria/classification
- Nontuberculous Mycobacteria/genetics
- Nontuberculous Mycobacteria/isolation & purification
- Nontuberculous Mycobacteria/physiology
- Nucleic Acid Hybridization
- Phylogeny
- Polymorphism, Restriction Fragment Length
- RNA, Bacterial/genetics
- RNA, Ribosomal, 16S/genetics
- Ribotyping
- Sequence Analysis, DNA
Collapse
Affiliation(s)
- Mark F Schinsky
- Washington University, School of Medicine, Barnes-Jewish Hospital, St Louis, MO 63110, USA
- Meningitis and Special Pathogens Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - Roger E Morey
- Meningitis and Special Pathogens Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - Arnold G Steigerwalt
- Meningitis and Special Pathogens Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - Michael P Douglas
- Meningitis and Special Pathogens Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - Rebecca W Wilson
- Department of Microbiology, University of Texas Health Center at Tyler, 11937 US Hwy 271, Tyler, TX 75708-3154, USA
- Center for Pulmonary and Infectious Disease Control, University of Texas Health Center at Tyler, 11937 US Hwy 271, Tyler, TX 75708-3154, USA
| | - Margaret M Floyd
- Tuberculosis/Mycobacteriology Branch, Division of AIDS, STD and TB Laboratory Research, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - W Ray Butler
- Tuberculosis/Mycobacteriology Branch, Division of AIDS, STD and TB Laboratory Research, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - Maryam I Daneshvar
- Meningitis and Special Pathogens Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - Barbara A Brown-Elliott
- Department of Microbiology, University of Texas Health Center at Tyler, 11937 US Hwy 271, Tyler, TX 75708-3154, USA
- Center for Pulmonary and Infectious Disease Control, University of Texas Health Center at Tyler, 11937 US Hwy 271, Tyler, TX 75708-3154, USA
| | - Richard J Wallace
- Department of Microbiology, University of Texas Health Center at Tyler, 11937 US Hwy 271, Tyler, TX 75708-3154, USA
- Center for Pulmonary and Infectious Disease Control, University of Texas Health Center at Tyler, 11937 US Hwy 271, Tyler, TX 75708-3154, USA
| | - Michael M McNeil
- Meningitis and Special Pathogens Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - Don J Brenner
- Meningitis and Special Pathogens Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - June M Brown
- Meningitis and Special Pathogens Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| |
Collapse
|
43
|
Daneshvar MI, Hollis DG, Weyant RS, Steigerwalt AG, Whitney AM, Douglas MP, Macgregor JP, Jordan JG, Mayer LW, Rassouli SM, Barchet W, Munro C, Shuttleworth L, Bernard K. Paracoccus yeeii sp. nov. (formerly CDC group EO-2), a novel bacterial species associated with human infection. J Clin Microbiol 2003; 41:1289-94. [PMID: 12624070 PMCID: PMC150304 DOI: 10.1128/jcm.41.3.1289-1294.2003] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
CDC eugonic oxidizer group 2 (EO-2) is a group of unclassified gram-negative bacterial strains isolated from various human sources. As determined by biochemical tests and analyses of fatty acid compositions, these organisms form a homogeneous group that appears to be distinct from but related to other Paracoccus species. Molecular studies were performed on a set of 13 EO-2 strains from various clinical sources and geographic locations in the United States and Canada to determine their relationship to the Paracoccus genus. Control strains were Paracoccus denitrificans ATCC 17741(T), P. versutus ATCC 25364(T), P. aminophilus ATCC 49673(T), P. solventivorans ATCC 700252(T), and Psychrobacter immobilis ATCC 43116(T), which are phenotypically similar to EO-2. Nearly complete (1,500-base) 16S rRNA gene sequencing of eight EO-2 strains showed a high level of sequence similarity (>99.3%) within the group, and a BLAST search of GenBank placed the EO-2 cluster in close proximity to Paracoccus species (95 to 97% similarity). DNA-DNA hybridization studies of 13 of the EO-2 strains showed all to be related at the species level, with >70% relatedness under stringent conditions and a divergence within the group of less than 2%. None of the Paracoccus control strains hybridized at >54% with any of the EO-2 strains. These results indicate that EO-2 represents a new Paracoccus species, the first isolated from human clinical specimens. A new species, Paracoccus yeeii, is proposed for the EO-2 strains. The type strain of P. yeeii is CDCG1212 (ATCC BAA-599 and CCUG 46822), isolated in Pennsylvania from dialysate of a 77-year-old male with peritonitis.
Collapse
Affiliation(s)
- Maryam I Daneshvar
- Meningitis and Special Pathogens Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Abstract
Ten strains of Lautropia mirabilis (ATCC 51599(T) and nine phenotypically similar clinical isolates) were examined for cellular fatty acid (CFA) composition to evaluate their chemical relatedness to known bacterial species and groups. The CFAs were liberated from whole cells by base hydrolysis, methylated, and analyzed by gas-liquid chromatography. CFA profiles were generated by using a commericial software package (MIDI, Newark, Del.). All strains tested had an identical CFA profile characterized by major amounts of 16:1omega7c (41%) and 16:0 (44%); smaller amounts (1 to 4%) of 3-OH-10:0, 12:0, 14:0, 15:0, and 18:1 omega7c; trace amounts (<1%) of 10:0, 18:2 and 18:0; and no cyclopropane acids. This profile was similar to the CFA profiles of Acidovorax delafieldii, Comamonas terrigena, and strains of an unclassified Centers for Disease Control group designated weak oxidizer group 1. CFA analysis, when supplemented by phenotypic characterization, is useful for the identification of L. mirabilis isolates.
Collapse
Affiliation(s)
- M I Daneshvar
- Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Public Health Service, U.S. Department of Health and Human Services, Atlanta, Georgia 30333, USA.
| | | | | |
Collapse
|
45
|
Teixeira LM, Carvalho MG, Espinola MM, Steigerwalt AG, Douglas MP, Brenner DJ, Facklam RR. Enterococcus porcinus sp. nov. and Enterococcus ratti sp. nov., associated with enteric disorders in animals. Int J Syst Evol Microbiol 2001; 51:1737-1743. [PMID: 11594604 DOI: 10.1099/00207713-51-5-1737] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Recent insights have been brought to the taxonomy of the genus Enterococcus by studies applying whole-cell protein analysis and DNA-DNA reassociation experiments, in addition to conventional physiological tests. Using these techniques, a group of 10 strains resembling the physiological group III of enterococcal species was characterized. Five strains were recovered from pigs and five from rats with enteric disorders. On the basis of the results of conventional physiological tests, the most likely identity of these strains was Enterococcus durans or Enterococcus hirae. Analysis of the electrophoretic whole-cell protein profiles showed two distinct clusters of virtually indistinguishable profiles: one composed of strains isolated from pigs, and one composed of strains isolated from rats. These protein profiles were not similar to the profiles of any previously described Enterococcus species. The results of DNA-DNA relatedness experiments were consistent with the results of the protein-profile analysis. The high levels of DNA relatedness found for pig isolates demonstrated that they belong to a new enterococcal species, for which the designation Enterococcus porcinus sp. nov. is proposed (type strain =DS 1390-83T =ATCC 700913T =CCUG 43229T =NCIMB 13634T). Strains isolated from rats were found to comprise another new species, for which the designation Enterococcus ratti sp. nov. is proposed (type strain =DS 2705-87T =ATCC 700914T =CCUG 43228T =NCIMB 13635T). This report provides data on the phenotypic and genotypic characterization of these two new enterococcal species, which may represent diarrhoeagenic pathogens for animals.
Collapse
|
46
|
Daneshvar MI, Hollis DG, Steigerwalt AG, Whitney AM, Spangler L, Douglas MP, Jordan JG, MacGregor JP, Hill BC, Tenover FC, Brenner DJ, Weyant RS. Assignment of CDC weak oxidizer group 2 (WO-2) to the genus Pandoraea and characterization of three new Pandoraea genomospecies. J Clin Microbiol 2001; 39:1819-26. [PMID: 11325997 PMCID: PMC88032 DOI: 10.1128/jcm.39.5.1819-1826.2001] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
CDC weak oxidizer group 2 (WO-2) consists of nine phenotypically similar human clinical isolates received by the Centers for Disease Control and Prevention between 1989 and 1998. Four of the isolates were from blood, three were from sputum, and one each was from bronchial fluid and maxillary sinus. All are aerobic nonfermentative, motile gram-negative rods with one to eight polar flagella per cell. All grew at 25 and 35 degrees C and were positive for catalase, urease (usually delayed 3 to 7 days), citrate, alkalinization of litmus milk, oxidization of glycerol (weakly), and growth on MacConkey agar and in nutrient broth without NaCl. All except one strain were oxidase positive with the Kovács method, and all except one isolate weakly oxidized D-glucose. All were negative for oxidation of D-xylose, D-mannitol, lactose, sucrose, maltose, and 20 other carbohydrates, esculin hydrolysis, indole production, arginine dihydrolase, and lysine and ornithine decarboxylase. Only two of nine isolates reduced nitrate. Broth microdilution susceptibilities were determined for all strains against 13 antimicrobial agents. Most of the strains were resistant to ampicillin, extended-spectrum cephalosporins, and aminoglycosides, including gentamicin, tobramycin, and amikacin, but they varied in their susceptibility to fluoroquinolones. High-performance liquid chromatographic and mass spectrometric analyses of the WO-2 group identified ubiquinone-8 as the major quinone component. The percent G+C of the WO-2 strains ranged from 65.2 to 70.7% (thermal denaturation method). All shared a common cellular fatty acid (CFA) profile, which was characterized by relatively large amounts (7 to 22%) of 16:1omega7c, 16:0, 17:0cyc, 18:1omega7c, and 19:0cyc(11-12); small amounts (1 to 3%) of 12:0 and 14:0; and eight hydroxy acids, 2-OH-12:0 (4%), 2-OH-14:0 (trace), 3-OH-14:0 (12%), 2-OH-16:1 (1%), 2-OH-16:0 (3%), 3-OH-16:0 (4%), 2-OH-18:1 (2%), and 2-OH-19:0cyc (3%). This profile is similar to the CFA profile of Pandoraea, a recently described genus associated with respiratory infections in cystic fibrosis patients (T. Coenye et al., Int. J. Syst. Evol. Microbiol., 50:887-899, 2000). Sequencing of the 16S rRNA gene (1,300 bp) for all nine strains indicated a high level (> or =98.8%) of homogeneity with Pandoraea spp. type strains. DNA-DNA hybridization analysis (hydroxyapatite method; 70 degrees C) confirmed the identity of WO-2 with the genus Pandoraea and assigned three strains to Pandoraea apista and three to Pandoraea pnomenusa, and identified three additional new genomospecies containing one strain each (ATCC BAA-108, ATCC BAA-109, ATCC BAA-110). This study also shows that Pandoraea isolates may be encountered in blood cultures from patients without cystic fibrosis.
Collapse
Affiliation(s)
- M I Daneshvar
- Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, PHS, U.S. DHHS, Atlanta, GA 30333, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Abstract
Tissues from nine species of plants and fungi were treated separately with eight solutions, including seven cytological fixatives (3.7% formaldehyde at pH 3.0 and 7.0, FAA at pH 3.0 and 7. 0, 1% glutaraldehyde at pH 3.0 and 7.0, and Lavdowsky's fluid at pH 3.0) and one storage buffer (SED=NaCl-EDTA-DMSO, pH 7.0). DNA from untreated tissue and SED-treated tissue was of high molecular weight (>50 kb). DNA from glutaraldehyde-treated tissues averaged 20 kb in length, while DNA from all other treatments averaged less than 8 kb in length. Each DNA was subjected to amplification using the polymerase chain reaction, followed by sequencing of 250 bp near the 3' end of the nuclear rRNA small subunit gene. Glutaraldehyde treatments (at pH 3.0 and 7.0) produced damaged bases at rates of 0. 0% to less than 0.1%. Treatments with Lavdowsky's fluid (containing mercuric chloride), FAA at pH 7.0, and SED produced rates of 0.0% to 3.6%. FAA at pH 3.0 produced rates of 7.6% to 15.6%. Nearly 100 attempts to amplify from specimens treated with 3.7% formaldehyde (at pH 3.0 and 7.0) failed, indicating extreme damage to the DNA.
Collapse
Affiliation(s)
- M P Douglas
- Environmental and Forest Biology, State University of New York, College of Environmental Science and Forestry, 1 Forestry Drive, Syracuse, NY 13210, USA
| | | |
Collapse
|
48
|
Bennett BK, Hickie IB, Vollmer-Conna US, Quigley B, Brennan CM, Wakefield D, Douglas MP, Hansen GR, Tahmindjis AJ, Lloyd AR. The relationship between fatigue, psychological and immunological variables in acute infectious illness. Aust N Z J Psychiatry 1998; 32:180-6. [PMID: 9588296 DOI: 10.3109/00048679809062727] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this paper is to explore the longitudinal relationships between physical and psychological symptoms and immunological factors following acute infective illnesses. METHOD Preliminary data from a prospective investigation of patients with serologically proven acute infectious illnesses due to Epstein-Barr virus (EBV), Ross River virus (RRV) or Q fever are reported. Patients were assessed within 4 weeks of onset of symptoms and then reviewed 2 and 4 weeks later. Physical illness data were collected at interview. Psychological and somatic symptom profiles were assessed by standardised self-report questionnaires. Cell-mediated immune (CMI) function was assessed by measurement of delayed-type hypersensitivity (DTH) skin responses. RESULTS Thirty patients who had been assessed and followed over the 4-week period (including 17 patients with EBV, five with RRV and eight with Q fever) were included in this analysis. During the acute phase, profound fatigue and malaise were the most common symptoms. Classical depressive and anxiety symptoms were not prominent. Initially, 46% of cases had no DTH skin response (i.e. cutaneous anergy) indicative of impaired cellular immunity. Over the 4-week period, there was a marked improvement in both somatic and psychological symptoms, although fatigue remained a prominent feature in 63% of subjects. The reduction in reported fatigue was correlated with improvement in the DTH skin response (p = 0.001) and with improvement in General Health Questionnaire (GHQ) scores (p < 0.01). CONCLUSIONS Acute infectious illnesses are accompanied by a range of nonspecific somatic and psychological symptoms, particularly fatigue and malaise rather than anxiety and depression. Although improvement in several symptoms occurs rapidly, fatigue commonly remains a prominent complaint at 4 weeks. Resolution of fatigue is associated with improvement in cell-mediated immunity.
Collapse
Affiliation(s)
- B K Bennett
- School of Psychiatry, University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | |
Collapse
|